July 2012 Issue

Building a Multicultural Team
By Megan Tempest, RD
Today’s Dietitian
Vol. 14 No. 7 P. 36

Dietitians who speak various languages and understand different cultures have an important role to play in improving patient care.

Mei, a Chinese American immigrant, was hospitalized after suffering a stroke. During Mei’s hospital stay, her doctor placed her on a cardiac diet. In broken English, Mei tried communicating her meal preferences to the hospital foodservice staff on several occasions, but she was routinely served foods she didn’t request and had never tasted before. She wanted traditional cuisine native to her country.

The language barrier between her and her doctors and nurses, coupled with the social isolation of a lengthy hospital stay, left Mei depressed and uninterested in eating. By the time she was discharged from the hospital to be admitted to a rehabilitation center, she’d lost 10 lbs on her already slight frame.

Mei’s formidable experience in the healthcare system, as a patient from another country who speaks little to no English, isn’t uncommon, since the diversity of the US population has grown exponentially and continues to do so. According to a 2010 census brief, the Asian population in the United States grew faster than any other racial group, increasing by 43%. Between 2000 and 2010, the nation’s Hispanic population accounted for more than one-half of the total US population growth. And more than one-third of the US population reported their race and ethnicity as something other than non-Hispanic white, representing a 30% growth throughout the decade.

Because of the growing diversity in the United States, hospitals and other healthcare institutions are realizing more than ever before the importance of building multicultural healthcare teams to improve the care of patients from various countries and ethnic and racial groups. Multicultural teams involve doctors, nurses, dietitians, and other allied health professionals who can speak other languages, serve as interpreters, and are familiar with different cultures and customs, enabling them to provide higher-quality healthcare.

What the Evidence Shows
Research has found that the multicultural healthcare model can improve outcomes. A study by Taylor and colleagues, published in the May 2002 issue of the Journal of the National Cancer Institute, reported that culturally and linguistically appropriate outreach interventions are an effective means to increasing the number of cervical screenings among Chinese women in North America, a population less likely to have routine Pap tests compared with other population subgroups.

In the February 2011 issue of the Journal of Urban Health, Gany and colleagues addressed the numerous social and economic barriers of Chinese immigrants, known to have high rates of various cancers and difficulty with keeping appointments for cancer treatments. Among a cohort of 82 Chinese immigrant cancer patients, missed appointments often were a result of misunderstandings during scheduling, which could have been prevented with the use of interpreters or a bilingual staff.

Another study by Gany and colleagues, published in the January 2011 issue of the Journal of Oncology Practice, sought to determine if a multidisciplinary, multilingual team could increase adherence to cancer treatment by reducing social and language barriers among Hispanic immigrants, a subgroup known to have poor adherence to cancer treatment and low cancer survival rates. Through access to trained, bilingual facilitators who assessed the needs of each patient and synchronized transdisciplinary services on their behalf, the study participants were more likely to keep their cancer treatment appointments and worry less about their care.

Cultural Competency in Action
A present-day example of a successful multicultural healthcare team is at work at Memorial Sloan-Kettering Cancer Center (MSKCC) located on the upper east side of Manhattan in New York.

Veronica McLymont, PhD, RD, CDN, director of food and nutrition services at the 425-bed hospital, which has eight affiliated community-based cancer treatment centers, describes the workforce as a diverse landscape of healthcare providers and support service staff from various cultural backgrounds. It’s essentially a multicultural healthcare team that reflects the patient population it serves.

McLymont is emphatic that the presence of a multicultural team is more than a means to achieving optimal patient satisfaction; it’s a matter of basic civil rights. “Healthcare is for everyone,” McLymont says. “We cannot discriminate on the basis of culture, religion, race, or gender. A team of multicultural individuals ensures these standards are withheld.”

At perhaps the most fundamental level, skilled language interpretation by professionals with a sound knowledge of healthcare systems and terminology is a critical element in providing culturally competent healthcare. “We believe communication is the cornerstone of effective, quality cancer care, from primary prevention to survivorship,” McLymont says. “When patients and providers speak the same language, patients are more likely to report positive physical and mental health outcomes.”

MSKCC established a language assistance program that McLymont says gives patients access to interpreters during doctor appointments and translators to help them understand important documents. Patients who aren’t proficient in the English language are identified at the first point of contact. They’re asked their language preference and offered free interpreter services. McLymont says a language assistance program is essential to preventing discrimination and disparities in quality of care that come from poor or limited communication between patients and healthcare providers. Moreover, McLymont says it’s an invaluable tool for reducing undue emotional stress on patients that comes from a language barrier and lifts the burden off patients’ families and friends who often act as interpreters on their behalf.

In addition to language interpretation, McLymont says a diverse, culturally competent workforce can impact quality of care by doing the following:

• Promoting higher productivity: Less time is spent miscommunicating. The healthcare team can meet the needs of patients and administer the proper care promptly; fewer appointments are missed; and nonadherence to medical treatments due to language barriers is reduced.

• Focusing on culturally sensitive customer service and patient-centered care: As a core component of quality healthcare, the Institute of Medicine describes patient centeredness as healthcare that “encompasses qualities of compassion, empathy, and responsiveness to the needs, values, and expressed preferences of the individual patient.”

• Upholding standards set by The Joint Commission: A diverse workforce meets the Joint Commission standard that states healthcare organizations must provide culturally competent care. The Joint Commission defines cultural competence as “the ability of healthcare providers and healthcare organizations to understand and respond effectively to the cultural and language needs brought by the patient to the healthcare encounter. Cultural competence requires organizations and their personnel to do the following: value diversity; assess themselves; manage the dynamics of difference; acquire and institutionalize cultural knowledge; and adapt to diversity and the cultural context of individuals and communities served.”

• Ensuring patient safety: With adept language interpretation and cultural competence on the part of healthcare providers, medical errors and the potential for dangerous drug interactions between medications prescribed by multiple healthcare providers are reduced. Patients are less likely to misunderstand their medical condition and have difficulty following their recommended treatment plan.

How RDs Can Offer Culturally Sensitive Care
Because food and culture go hand in hand, dietitians can play a vital role in providing culturally sensitive care to patients. Lilly Cheng, PhD, cochair of the Asian Task Force, director of the Chinese Studies Institute, and a professor of speech, language, and hearing sciences at San Diego State University, is an advocate for the role of the dietitian in multicultural healthcare.

“Building a multicultural team in any service industry is important because our nation is a nation of diversity,” Cheng says. “We need people who can understand cultural and ethnic practices such as kosher laws, a strict vegan diet, that certain religious beliefs influence consumption of animals, that in some cultures food is eaten cooked and never raw; in other cultures people consume rice instead of pasta and use chopsticks instead of knives. When you’re sick, you want comfort food. But the definition of comfort food is very different from culture to culture. A peanut butter and jelly sandwich would be considered unacceptable in some cultures. All these things must be understood by a team of people who are either from these different groups or who have multicultural experience or expertise.”

McLymont encourages RDs and the supporting healthcare team that provides food and nutrition services to diversify patient menu options to meet ethnic, cultural, and religious food preferences and ensure menus are translated in multiple languages that match the cultural makeup of the patient population. RDs can be a driving force behind the establishment of a foodservice team that has the ability to make special accommodations for patients on the basis of their religious, ethnic, and cultural preferences, McLymont says. The opportunities for dietitians to improve the quality of care for patients of different ethnic and cultural backgrounds are plentiful. With input from McLymont and Cheng, the following three scenarios demonstrate how RDs can provide culturally sensitive patient care.

Scenario 1: A Patient From India
An Indian patient is admitted for a bone marrow transplant. He’s a strict vegetarian, is neutropenic, and has been prescribed a low-microbial diet. The patient has difficulty understanding the complexity of the low-microbial diet and whether he can continue to eat his favorite vegetarian meals.

What you can do: The dietitian can partner with the hospital chef to provide the patient’s favorite Indian foods, such as biryani and dal and curry, which reflect the patient’s cultural and religious practices while complying with his low-microbial diet. By offering familiar foods, the patient’s appetite will improve. He’ll be relieved of the anxiety regarding his diet and the worries of being treated for cancer in a foreign country.

Scenario 2: A Patient From South Africa
A South African patient is taking herbal medicines traditionally used in his culture. His healthcare providers have told him that the herbs are contraindicated with lymphoma treatment. The patient becomes frustrated because the herbs have been used for centuries in his culture, and he firmly believes they’re helping his body fight the disease.

What you can do: The dietitian can discuss with the patient and his family the potential adverse interactions of the herbal medicines. By conveying that the herbs may be dangerous and interfere with the efficacy of the medical treatments, the patient and family may accept that discontinuing the herbal medicines is in the patient’s best interest.

Scenario 3: A Patient From Asia
An Asian patient who doesn’t speak English is severely lactose intolerant. He’s served milk, cheese, and other dairy products routinely during his hospital stay. However, because he’s hungry, he consumes some of the dairy products and experiences vomiting, diarrhea, and dehydration.

What you can do: The dietitian should discuss alternative food choices with the patient through an interpreter and work with the chef to provide lactose-free sources of milk and other nutrient-rich foods to avoid compromising the quality of his nutritional intake. The dietitian can speak with the patient’s family, with an interpreter if needed, to better understand what types of foods the patient typically eats and what foods he’s most likely to enjoy while hospitalized. The outcome is that the patient will be served food he enjoys and that alleviates his gastrointestinal symptoms and dehydration, and he’ll experience an improved emotional state.

Need for Better Education
To plant the seeds of cultural competence in dietitians and other healthcare providers, Cheng believes that the curriculum in the nation’s educational institutions must focus on multiculturalism and strive to recruit globally competent educators.

“I’ve been doing this for 30 some years,” Cheng says. “It won’t happen overnight; however, slowly but surely we’ll see a paradigm shift in terms of what it means to provide nutrition support.”

Cheng conveys what’s perhaps the heart of the issue: Do we want our patients to survive or do we want them to thrive? “If we want patients to thrive, healthcare providers must consider the cultural and ethnic background of their patients and attempt to learn from them as well as their families.”

— Megan Tempest, RD, is a freelance writer based in Colorado.